Confronting the dialectic between quality and access in early psychosis care in the United States: Finding the synthesis by leveraging psychological expertise

Coordinated specialty care (CSC) is the dominant model for early psychosis care in the United States, representing a proactive recovery-oriented approach to serious mental illness in its early stages. CSC involves broad multidisciplinary support for participants, including from psychologists in some CSC teams, encompassing educational and vocational support, medication management, psychotherapy, case management, peer support, and family interventions. CSC programs have proliferated in the last 20 years, leading to a quality-access dialectic, where increasing access to treatment simultaneously prompts concerns about care quality, particularly in the context of staffing shortages and funding limits. Evidence-based psychosocial treatment, including psychotherapy, is an integral part of CSC, yet workforce training deficits, workforce turnover, and CSC financing pose threats to intervention fidelity and thus CSC participants' ability to access high-quality care. We propose an enhanced role for psychologists as a way of resolving the quality-access dialectic in the area of psychosocial treatment, specifically evidence-based therapy. We describe the potential of psychologists' skills in clinical supervision, formulation, evidence-based interventions and measurement-based care, drawing on practice examples. After considering possible limitations, we outline implementation models, for example, drawing on Early Psychosis Intervention Network and Project Extension for Community Healthcare Outcomes. We conclude with four recommendations: Psychologists should be placed in CSC team or network-leadership roles; psychological expertise should be made available to CSC teams for training, consultation, and technical assistance; psychological expertise should be used to address CSC implementation challenges; and research is needed to demonstrate psychologists' value to stakeholders. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Central Assessment of Psychosis Service: A Tele-evaluation Service to Support Early Identification of Psychosis

Duration of untreated psychosis (DUP) is a reliable predictor of longitudinal psychosis trajectory. The limited availability of specialized assessment needed for early identification contributes to a lengthy average DUP in the United States. This column outlines the development of the Central Assessment of Psychosis Service (CAPS), a novel tele-evaluation service that extends specialized expertise in screening and assessment of psychosis and psychosis risk to publicly funded early psychosis clinics. Preliminary implementation outcomes among the first five CAPS sites suggest that CAPS is acceptable, appropriate, and feasible to implement. Programmatic data collection is underway and will be reported at a future date.

A Review of Forensic Fellowship Training: Similar Challenges, Diverse Approaches

OBJECTIVE

As the specialty of forensic psychiatry and the numbers of justice involved individuals with mental illness continue to grow, forensic education is receiving more attention. To add to this discussion, the authors reviewed current training practices in forensic psychiatry fellowship programs.

METHODS

As part of a project funded by the state legislature looking at psychiatry and psychology training, with special focus on state hospital partnerships, the authors interviewed and surveyed forensic psychiatry fellowship program directors and conducted site visits to select programs. Given the mandate, special attention was given to programs with state hospital and psychology training affiliations.

RESULTS

The literature and fellowship directors identified several key features and challenges for forensic training programs. Forensic fellowships focused primarily on evaluations and consultations but differed in their offerings related to training in treatment, scholarship, and particular types of evaluations. Common concerns included maintaining adequate funding, variety of training experiences, adequate faculty time, and adequate institutional support. Directors described cultivating institutional support by demonstrating mutual benefit as particularly important for securing resources.

CONCLUSION

Forensic fellowships operational during the 2016-2017 academic year offered a range of forensic training activities, but experienced common challenges such as inadequate funding and faculty supervision. Empirical studies are needed to evaluate the relationship between programmatic offerings, the noted challenges, and acquired competencies.

Preliminary Evaluation of Washington State's Early Intervention Program for First-Episode Psychosis

OBJECTIVE

Early intervention programs are designed to address the needs of youths experiencing first-episode psychosis (FEP). Washington State developed New Journeys, a network of coordinated specialty care programs for FEP. In this study, the authors have outlined components of the New Journeys model and preliminary findings since its initial implementation.

METHODS

Youths and young adults diagnosed as having psychosis (N=112) completed measures at and after intake on a range of mental health assessments and functional outcomes for the first 12 months of treatment. Administrative data including state-funded emergency department and psychiatric hospitalizations were assessed 24 months before and after intake. Generalized estimating equations were used to assess change over time on multiple measures of mental health status.

RESULTS

Compared with their condition at intake, clients had significant decreases in symptoms of anxiety (β=-2.48, p<0.001), psychotic experiences (β=-3.37, p<0.05), and clinician-rated psychotic symptoms (β=-1.47, p<0.05) during treatment. Additionally, quality of life (β=-5.95, p<0.001) and school attendance (odds ratio=1.42, p<0.05) significantly improved during treatment. Administrative data indicated that postintake, clients were less likely to visit the emergency department for psychiatric reasons (β=0.22, p<0.05), utilize community psychiatric inpatient services (β=0.31, p<0.001), and utilize public assistance (β=0.71, p<0.05) compared with 24 months before intake.

CONCLUSIONS

New Journeys clients experienced improved clinical and functional outcomes during their first year of treatment, and rates of state-funded service utilization decreased during their treatment.

A technology-assisted life of recovery from psychosis

Developments in digital health technologies have the potential to expedite and strengthen the path towards recovery for people with psychosis. This perspective piece provides a snapshot of how a range of digital technologies can be deployed to support a young adult’s efforts to cope with schizophrenia-spectrum illness. In conjunction with a day in the life of this individual, we provide examples of innovations in digital health research designed for this clinical population, as well as brief summaries of the evidence supporting the usability, feasibility, or effectiveness of each approach. From early detection to ongoing symptom management and vocational rehabilitation, this day-in-the-life vignette provides an overview of the ways in which digital health innovations could be used in concert to augment, scaffold, and enhance schizophrenia-spectrum illness management and recovery.

Procedural justice in mental health courts: judicial practices, participant perceptions, and outcomes related to mental health recovery

Research on mental health courts (MHCs) to date has been disproportionately focused on the study of recidivism and reincarceration over the potential of these problem solving courts to facilitate the recovery process and affect the slope of recovery. This study attempts to shift the focal point of interest from well-established criminal justice outcomes to the experiences and perceptions of MHC participants. The authors hypothesize that the actions of MHC judges that are consistent with procedural justice theory will engender high perceptions of procedural justice among this sample of divertees with SMI. Defendant perceptions of procedural justice in 4 NYC-area MHCs were also compared to those of uninvolved observers. Results suggest that defendant perceptions are distinct from observer perceptions, which tended to be more sensitive to the differences in judges between the four courts. Overall, participants' perceptions of procedural justice were moderate and increased between baseline and 4-month follow-up. Procedural justice was negatively correlated with symptoms at baseline and was positively correlated with participant's attitudes toward their own recovery. Between baseline and 4-month follow-up, participants in our sample tended to increase in perceptions of procedural justice; interestingly, the increase in procedural justice was associated with a decrease in symptoms but not to an increase in attitudes toward the recovery. Implications and future directions are discussed.

Reliability, Validity, and Predictive Utility of the 25-Item Criminogenic Cognitions Scale (CCS)

Theory, research, and clinical reports suggest that moral cognitions play a role in initiating and sustaining criminal behavior. The 25 item Criminogenic Cognitions Scale (CCS) was designed to tap 5 dimensions: Notions of entitlement; Failure to Accept Responsibility; Short-Term Orientation; Insensitivity to Impact of Crime; and Negative Attitudes Toward Authority. Results from 552 jail inmates support the reliability, validity, and predictive utility of the measure. The CCS was linked to criminal justice system involvement, self-report measures of aggression, impulsivity, and lack of empathy. Additionally, the CCS was associated with violent criminal history, antisocial personality, and clinicians' ratings of risk for future violence and psychopathy (PCL:SV). Furthermore, criminogenic thinking upon incarceration predicted subsequent official reports of inmate misconduct during incarceration. CCS scores varied somewhat by gender and race. Research and applied uses of CCS are discussed.